| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
191 |
94 |
$90K |
| D9430 |
|
980 |
838 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
446 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
491 |
491 |
$22K |
| D2954 |
|
204 |
93 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
284 |
284 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
82 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,499 |
1,005 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
858 |
856 |
$10K |
| D1120 |
Prophylaxis - child |
221 |
219 |
$7K |
| D1110 |
Prophylaxis - adult |
63 |
62 |
$5K |
| D2332 |
|
55 |
14 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
41 |
$3K |
| D1320 |
|
229 |
224 |
$3K |
| D0274 |
Bitewings - four radiographic images |
103 |
103 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0350 |
|
20 |
13 |
$150.00 |